When patients of Judith Walsh, FACP, need a referral to a pulmonologist or cardiologist, she knows exactly where to send them. But when patients need a referral to a psychiatrist, the internist comes up empty-handed.

“With any other illness I can recommend Dr. Brown or Dr. Smith, but with mental illness, it’s like a black box,” said Dr. Walsh, an associate professor of medicine who sees patients at the Women’s Health Primary Care Practice at the University of California, San Francisco. “Patients have to call a separate phone number to get hooked into finding someone, and I don’t know who is on the approved list.”

Dr. Walsh’s experience is a common one, internists say. Treatment of disorders like depression and schizophrenia are typically “carved-out”—contracted to an independent provider—by managed care plans. Having a separate insurer makes it especially difficult for internists to coordinate care, said Kurt Kroenke, MACP, professor of medicine at Regenstrief Institute and Indiana University in Indianapolis.

“There’s a lack of integration among internists and mental health specialists, and it preserves an unnecessarily dualistic system,” Dr. Kroenke said.

Carve-outs are just one example of how insurers treat mental illness differently from other medical illness. Nearly 90% of group health plans impose stricter financial limitations and treatment restrictions on mental health and addiction care than other medical care, the Government Accountability Office (GAO) says. Differences range from higher co-payments and deductibles to lower visit limits.

The coverage imbalance has gained notice recently with the introduction of several bills in Congress to institute “parity”—to make insurance benefits for mental illnesses equal to those of other physical ailments. If passed, the bills could potentially benefit internists and patients in a number of ways, from freeing up emergency department space to improving medication adherence for all sorts of conditions.

The price of parity

For non-mental health benefits, a typical group insurance plan might cover unlimited hospital days and outpatient visits and pay 80% of covered services, a 2002 GAO report said. For mental health benefits, however, the same plan might cover only 30 hospital days and 20 outpatient visits per year and pay only 50% of covered services, barring a state parity law, the report said. Individual market plans face even greater restrictions, it said.

The coverage limits imposed on mental health treatment can mean patients aren’t getting the care they need. Twenty outpatient visits per year, for example, often isn’t adequate to treat the long-established behavioral and cognitive patterns of mental illness, said Steve Rasmussen, MD, medical director of Butler Hospital, a psychiatric and substance abuse facility in Providence, R.I.

“Let’s say you start seeing a very ill patient with an eating disorder. You have an option to see the patient for 20 visits, but what if she needs 50 to deal with the underlying issues?” Dr. Rasmussen said.

High co-payments are a problem as well, he added. Medicare patients, for example, are charged a 50% copayment for outpatient mental health visits.

“Many of these patients have a serious enough mental illness that they are disabled, yet they have to somehow come up with a 50% copayment to treat an illness which has made them unable to work,” Dr. Rasmussen said.

Several internists also noted that, in their experience, it is more difficult and time-consuming to get a patient approved for admission to a hospital for a mental illness than for a physical illness.

“There are a lot more hoops to jump through than there are for any other medical thing. It takes hours and hours of talking to people to make it happen,” Dr. Walsh said. “You constantly have to justify why a patient needs to be admitted instead of treated on an outpatient basis.”

Research backs up this claim. Psychiatry had the highest number of cases and patient days denied by insurers compared with oncology, neurology and family practice at one tertiary care, academic health center between 1998 and 2001, a study found. The most common reason for psychiatric denial was that the allowable dollar or hospital day limit had been exceeded, according to the July 2004 study in the Journal of Behavioral Health Services & Research.

Some internists have had so much trouble getting insurers to cover office visits when they are coded for a mental illness that they resort to other measures, said Francis X. Solano, FACP, medical director at the Center for Quality Improvement and Innovation at the University of Pittsburgh Medical Center.

"It's disgustingly to the point where many doctors avoid writing depression as a diagnosis because they are afraid the claim will get denied."—Francis X. Solano, FACP

“It’s disgustingly to the point where many doctors avoid writing depression as a diagnosis because they are afraid the claim will get denied,” Dr. Solano said. “Most people who are depressed or anxious have fatigue or insomnia, or other symptoms that doctors can use to code the diagnosis instead.”

The drug default

In general, Medicare and private payer plans make it less expensive for consumers to get drug prescriptions from primary care doctors than to get therapy from specialists, experts said. This, along with the difficulty that busy internists have in finding a mental health specialist for their patients, leads to a reliance on medication to address mental illness, said Henry Harbin, MD, a psychiatrist and former CEO of two managed behavioral healthcare organizations.

“Most primary care offices are not equipped to provide a full range of behavioral diagnostic and treatment services. The most common intervention by the primary care office for these disorders is the prescription of psychotropic medications,” said Dr. Harbin during March testimony before the Health Subcommittee of the U.S. House Ways and Means Committee.

David Winchester, ACP Associate Member, a resident physician at the University of Virginia with a patient panel at the residents’ clinic, agreed that physicians are “unequivocally” more likely to prescribe drugs as the first course of treatment.

“I try to encourage psychotherapy for patients who have decent health insurance or money to pay out-of-pocket, but frequently therapy is not an option for my patients,” Dr. Winchester said. “We want to help people, and medication is readily available.”

If internists had some assurance that counseling would be covered as well as medication, they would be more likely to suggest it as an alternative, Dr. Winchester added.

The problem with limiting treatment to drugs is that it isn’t always enough. The American Psychiatric Association recommends that for certain illnesses—like severe or recurrent major depression—a combination of drugs and therapy works better than either drugs or therapy alone.

“Primary care physicians are an essential part of the health care system for behavioral disorders, but when this becomes the only option, we are depriving many patients of the most effective and medically appropriate treatment,” Dr. Harbin said.

Indeed, the National Comorbidity Replication Study, published in the June 2005 Archives of General Psychiatry, found that 12.7% of mentally ill patients treated in the general medical setting received minimally adequate care, compared with 43.8% in the specialty mental health sector.

The ED boomerang

When the cost of co-payments gets too high, or annual visit limits run out, patients don’t just seek refuge in their primary care internist’s office. Some land in overburdened emergency departments.

“I recently had a depressed patient who was paying out of pocket to see a private psychiatrist. When she could no longer afford it, she stopped going, hit a rough patch and wound up in the emergency department,” said Ralph Lanza, FACP, an internist in suburban Philadelphia. “Then she was admitted to the psychiatric unit of the hospital.”

Victor Pinkes, MD, chair of emergency medicine at Landmark Medical Center in Woonsocket, R.I., said he sees mentally ill patients in his emergency department all the time.

“You have a significant number of suicide attempts; you have patients with symptoms of schizophrenia, like hallucinations, and they feel unsafe. You have patients who have substance abuse tied to mental illness,” Dr. Pinkes said. “You have people with anxiety disorders come in with shortness of breath and chest pain, and that’s a prolonged workup.”

Such patients often create a huge strain on the functioning of a department that is already overcrowded and overworked, he added, because they stay in the emergency department three to four times longer than most other patients.

“It takes a long time for them to detox or be calm or be able to be approached,” Dr. Pinkes said. “It’s disruptive to the care of all the patients in the ED if they are violent and/or verbally loud or abusive, or if they need to be physically or chemically restrained, and then watched.”

Many emergency department patients go on to get admitted. An April study by the Agency for Healthcare Research and Quality found that nearly a quarter of adult stays in U.S. community hospitals involved mental health or substance abuse disorders.

The mind-body connection

Mentally ill patients are also less likely to care for their overall health. Depressed patients are three times as likely as non-depressed patients to be non-compliant with medical treatment regimens for ailments like end-stage renal disease, cancer and rheumatoid arthritis, according to a July 2000 meta-analysis in the Archives of Internal Medicine. And a March 2005 review in the Journal of Diabetes and Complications found that depressed diabetics are significantly less likely to adhere to medication than diabetics who aren’t depressed.

Dr. Winchester said he’s noticed his mentally ill patients are less apt to adhere to medication regimens, exercise or a healthy diet.

“I have mentally ill patients who come in and they aren’t taking their blood pressure or diabetes or heart medication because they don’t have good insight or understand the need,” Dr. Winchester said. “So they get worse and worse in their physical health as well as their mental health.”

If one considers some of the cardinal features of depression —apathy, fatigue, listlessness—it makes sense that a depressed patient wouldn’t care for his or her other diseases, Dr. Solano said.

“Very few people care about taking care of their heart or their diabetes if they are depressed,” Dr. Solano said. “All they want to do is sit around, sleep or die.”

To be sure, a federal parity law won’t solve every glitch in the mental health care system. States with strong parity laws still experience trouble, like reimbursement snags and a shortage of psychiatrists. Such issues run too deep for a single fix, but instituting parity is a step in the right direction, said Andrew Sperling, JD, director of federal legislative advocacy at the National Alliance for the Mentally Ill.

“We’re not trying to fix every problem in the health insurance system. We’re not even trying to mandate that mental health be covered. We’re just saying that if you do cover it, you can’t discriminate. You have to do things on equal terms,” Mr. Sperling said.

A provision in the Children’s Health and Medicare Protection Act, H.R. 3162, would reduce Medicare’s 50% copayment for outpatient psychotherapy to 20%.

The Medicare Mental Health Modernization Act of 2007 (H.R. 1663) would do the same, as well as eliminate Medicare's 190-day lifetime limit on inpatient services at psychiatric hospitals.

Senate Bill 558 and House Bill 1424 both seek parity in terms of inpatient day limits and outpatient visit limits, as well as deductibles, copayments and cost sharing. The Senate bill would let employers decide which diagnoses are covered or excluded, while the House bill is more specific about what gets covered. Neither bill would preempt any state parity law that offers greater consumer protections than the federal law.

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